Alternative Laparoscopic Intracorporeal Pringle Maneuver by Huang’s Loop

Original Scientific Report with Video

Abstract

Aim

This paper aims to describe an intracorporeal tourniquet method for laparoscopic Pringle maneuver (PM).

Methods

One shortened Foley tube with side-hole on the tip was put into the abdomen. Then, the tail was pulled out through the side-hole to make a loop to encircle porta hepatis for inflow control.

Result

It is easy to keep the tension by a metallic clip, and when released, the clip can be removed and the loop loosened.

Conclusion

Therefore, PM could be performed inside the abdomen without special instrument nor extra trocar port. The intracorporeal Pringle maneuver with Huang’s loop could be routinely used during laparoscopic liver resection even for a laparoscopic beginner because it is so easily learnt, safe, and effective.

Introduction

As is known, the liver sits inside the rib cage, and it is difficult to approach and mobilize this organ without a huge wound for creating a satisfactory operative field. Usually, one subxiphoid midline incision with bilateral subcostal extension is suitable for conventional open laparotomy. Great wound pain, muscle and nerve injury, atelectasis due to poor respiratory movement, wound infection, long hospital stay, and terrible scar are the most troublesome problems for postoperative care. Minimal invasive surgery for hepatectomy could prevent such problems. Laparoscopic liver resection has evolved in the past several years under the great improvement of anatomic knowledge, surgical tools, and advanced skills. Even more complicated laparoscopic major anatomic resections, such as right anterior, right posterior sectionectomy and right hemihepatectomy, have been reported recently. However, the main concern is still intraoperative hemorrhage. The Pringle maneuver, first described in 1908, is the simplest method for inflow occlusion when doing open liver surgery. When inflow is limited by the hepatic pedicle clamping, laparoscopic liver resection would be performed more smoothly due to reduced intraoperative blood loss. Some of the studies also mention that routine adoption of laparoscopic Pringle maneuver facilitates low conversion rates without liver injury [1].

Because hemorrhage during parenchymal transection is still a challenge even for an experienced surgeon, it is the primary reason for conversion to laparotomy. When doing open liver surgery, intermittent hepatoduodenal pedicle clamping is a popular method for inflow blood occlusion, the so-called Pringle maneuver. We attempted to perform this method in laparoscopic liver resection. We used the keywords such as “laparoscopic liver resection,” “laparoscopic Pringle maneuver,” and “laparoscopic hepatoduodenal ligament clamping” for a search in PubMed. In many studies, different impressive modalities of vascular occlusion to decrease blood loss have been published. Most of the studies describe the extracorporeal method using a 5-mm trocar [2], but few studies describe the intracorporeal method [3, 4, 5]. The purpose of this paper is to describe a new intracorporeal, effective, and facile method for the Pringle maneuver during laparoscopic liver resection by an easily made rubber tube, named Huang’s loop.

Methods

This method has been used routinely by the Division of General Surgery, Kaohsiung Medical University Hospital since August 2016, especially for anatomic resections. When doing anatomic resections such as laparoscopic right hemihepatectomy, right anterior and posterior sectionectomy, we clamp the right main glissonian pedicle, right anterior and posterior glissonian branch individually. Therefore, only when doing extra-glissonian pedicle approach or bleeding from liver transection surface do we perform laparoscopic Pringle maneuver for inflow control. Once the pneumoperitoneum is established up to 15 mmHg, hepatoduodenal ligament is identified. The procedure is described as follows: Usually, we use 3–4 trocars (11 mm × 2, 5 mm × 1 or 2) to perform all operations. Central vein pressure is usually controlled below 5 mmHg. One 14-French Nélaton urethral catheter (Foley tube) is needed to perform this procedure (Fig. 1a). The tube is shortened around 15 cm long from the tip without specific process (Fig. 1b), and then it is placed into the abdominal cavity from the 11-mm trocar. Once the lesser omentum is opened, the tip of the Foley tube is held by the left-hand grasper to pass through the foramen of Winslow without any instrument guidance (Fig. 2a, b). When the tip of Foley tube is seen in the lesser sac, it is pulled out by a sharp right-hand grasper, such as the dolphin grasper (Fig. 2c). Then, the right-hand grasper is inserted into the side-hole of the Foley tip to grab the tail and the tail is pulled out to make a circle loop (Fig. 2d, e, f). When performing the Pringle maneuver, the loop is tightened and the tension is held just by one hemoclip above the cross perpendicularly (Figs. 1f, 2g). While releasing the Pringle maneuver, the hemoclip can then be removed easily and the circle loop is loosened.
Fig. 1

Demonstrating the preparation of Huang’s loop: a A 14 French Nélaton urethral tube. b Shortened to 15 cm long. c The dolphin grasper is passed through the side-hole. d Grabbing the tail. e Pulling the tail through the side-hole. f Endo clip is then applied over the cross perpendicularly. g/h Huang’s loop is completed

Fig. 2

Intraoperative sequence of laparoscopic Pringle maneuver by Huang’s loop

Discussion

What are the differences between Huang’s loop and other methods previously published? When the extracorporeal clamping is used, an additional 5-mm trocar would be needed for external manipulation. Usually, the port is set on lateral subcostal site for a more easily approach to the hepatoduodenal ligament perpendicularly. Some surgeons have found that when performing the extracorporeal Pringle maneuver and using a tourniquet from the same port, the forceps and the tourniquet catheter would interfere with each other [4]. Nevertheless, Huang’s loop does not require the extra port because it is all performed intracorporeally. Since no tape is extracted outside the body, interference is reduced while intracorporeal manipulation is performed.

Some specific instruments may be needed for encircling the hepatoduodenal ligament to overcome the blind deployment of a tape between the pedicle and the vena cava, such as the biliary scope [6], laparoscopic articulating grasper, endo intestine clip [5], or the Endo Retract Maxi device, but these are not readily available in every hospital and not routinely used. Furthermore, when the extracorporeal method is performed, the grasper must cross the hepatic pedicle horizontally by a 5-mm trocar placed along the axillary line in the right flank, which is also elucidated by Rotellar et al. [2]. The most concerning problem during the laparoscopic hepatoduodenal ligament clamping is that injury to the portal vein or vena cava by a hard instrument might occur. To mitigate this problem, we pass the firm tip through Winslow’s foramen without specific guidance; therefore, unnecessary risk of porta hepatis injury could be prevented.

While mentioning the material encircling the hepatoduodenal ligament, we believe that a rubber tube is better than a tape or a metallic device. The characteristics of a rubber tube are softness, smoothness, and flexibility; thereby, the structures within the porta hepatis could be held gentler.

Other reason why we use the Foley tube is that it has a nature side-hole over the tip. The tube is usually shortened around 15 cm long from the tip without specific process, and then the cutting end is pulled out through the tip side-hole to perform a loop for encircling the porta hepatis. Then, an Endo clip (Autosuture, Large) is used to fix the loop just above the side-hole. But if tape is used, a specific material (Rumel tourniquet and hemo lock) would be needed to hold the tape if performed intracorporeally. Besides, it is difficult to remove the hemo lock without an energetic device like an ultracision scalpel [3]. Why is a 14 Fr. urethral catheter chosen? This is because the 12 Fr. is too soft to pass through the Winslow’s foramen, while the 16 Fr. is too thick for Endo clip application. In conclusion, a Foley tube with Endo clip is more popular, available, and cheaper to be applied.

It is also easy to declamp the tourniquet loop to retain the portal flow by removing the Endo clip over the Foley tip and to loosen the loop without obvious friction. Besides, this procedure could be done repeatedly when surgeons do parenchymal transection under a variable ischemic period from 10 to 15 min if bleeding from transection surface occurs.

Once Huang’s loop is prepared, the tube is easily identified to perform laparoscopic Pringle maneuver when a massive bleeding occurs. Not only is the yellow color different from blood color, but it will also not sink into the blood just as the cotton tape does.

Compared with the six-loop, an impressive intracorporeal method published in 2012 by Dr. Chao [4], Huang’s loop is easier to make and hold via Endo clip. The metallic clip is safer than a curved round needle when maintaining the tension to prevent penetration problems occurring accidentally. Also, it could be time-consuming to make the six-loop and to insert the Nélaton tube through the arm of the T-tube intracorporeally. Yet, great appreciation is given to the six-loop. Its primary schema inspires the development of Huang’s loop.

If the patient had received biliary surgery such as cholecystectomy, cystoduodenostomy, hepaticojejunostomy, or antrectomy with BI or BII anastomosis, it would be more difficult to pass the tip through the foramen of Winslow due to adhesion. However, such a limitation happens likewise to other methods of intracorporeal Pringle maneuver.

Conclusion

From laparoscopic partial hepatectomy to major anatomic resection, laparoscopic Pringle maneuver by Huang’s loop should be prepared for any kind of liver resection if possible. It is not only handy and accessible to acquire, but also an effective way to control bleeding in the surgery. No absolute contraindications to this procedure exist, but relative contraindications might be considered in patients with liver cirrhosis or adhesion due to previous liver surgery. In cirrhotic patients, clamping time should be reduced to 10 min to prevent intolerable ischemia. If severe adhesion over hepatoduodenal ligament found in the laparoscopic surgery, any method could be dangerous to cause the vital vessels injury violently.

Notes

Compliance with ethical standards

Conflict of interest

All the authors declare that they have no conflict of interests.

Supplementary material

Supplementary material 1 (MP4 139975 kb)

References

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Copyright information

© Société Internationale de Chirurgie 2018

Authors and Affiliations

  1. 1.Division of General SurgeryKaohsiung Medical University HospitalKaohsiungTaiwan
  2. 2.Division of General SurgeryKaohsiung Municipal Ta-Tung HospitalKaohsiungTaiwan

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